Peri-procedural Patient Management in the Cath Lab

Peri-procedural Patient Management in the Cath LabManagement in the Cath LabManagement in the Cath Lab

Young Hak Kim MD PhDYoung-Hak Kim, MD, PhD

Department of Cardiology University of Ulsan College ofDepartment of Cardiology, University of Ulsan College of Medicine, Heart Institute, Asan Medical Center, Seoul, Korea

Cardiac CatheterizationCardiac Catheterization

Activity in the Cath RoomActivity in the Cath Roomyy• Diagnosis of cardiac disease

C di bi- Cardiac biopsy- Cardiac catheterization

• C t di• Coronary artery disease : - Percutaneous coronary intervention

• Val lar heart disease• Valvular heart disease- Mitral stenosis, pulmonic stenosis, aortic stenosis

• Congenital heart disease• Congenital heart disease- ASD, PDA, VSD

• Arrhythmia• Arrhythmia- Electrophysiologic study

Pacemaker ICD implantation- Pacemaker, ICD implantation

Coronary Artery DiseaseCoronary Artery Disease

A h l iA h l iAtherosclerosisAtherosclerosis Myocardial Myocardial infarctioninfarctionAnginaAngina

AsymptomaticAsymptomaticstenosisstenosis Plaque rupturePlaque rupture

gg

DeathDeath

2020 3030 4040 5050 60 yrs60 yrs

Coronary Arteryy y

Conductance vessel to s ppl blood floto supply blood flow to the myocardium

Supply of oxygen d t i tand nutrient

Coronary AngiographyCoronary Angiography

Percutaneous Coronary InterventionPercutaneous Coronary Interventionyy

Percutaneous Mitral Balloon Valvuloplastyp yTo treat mitral stenosis

Cardiac BiopsyCardiac Biopsyp yp y

Electrophysiologic StudyTo detect and treat abnormal conductance

Electrophysiologic StudyTo detect and treat abnormal conductanceTo detect and treat abnormal conductanceTo detect and treat abnormal conductance

Implantable Caroverter DefibrillatorI t l h k t t t t i l t h di

Implantable Caroverter DefibrillatorI t l h k t t t t i l t h diInternal shock to treat ventricular tachycardiaInternal shock to treat ventricular tachycardia

Pacemaker InsertionPacemaker InsertionTo treat conduction delayTo treat conduction delay

B

Catheter to RA

Battery

Catheter to RA

C th t t RVCatheter to RV

AtrialAtrial SeptalSeptal Defect ClosureDefect ClosureAtrialAtrial SeptalSeptal Defect ClosureDefect ClosureAtrialAtrial SeptalSeptal Defect ClosureDefect ClosureAtrialAtrial SeptalSeptal Defect ClosureDefect Closure

Preprocedural ManagementPreprocedural Managementp gp g

• Physical and emotional status• Baseline lab test CBC Cr PT/aPTTBaseline lab test-CBC, Cr, PT/aPTT• NPO• Skin preparation• IV line – left side (antecubital vein for (

adenosine infusion) • MedicationMedication

Medications before PCIMedications before PCI

• Aspirin for all coronary patients

• Cl id l (l di 300 600 )• Clopidogrel (loading 300-600 mg)

• Beta-blocker, nitrate, calcium channel blocker -, ,not necessary except MI

• IV nitrate – not necessary.

• Heparin – unstable patientsepa u stab e pat e ts

Post-procedural ManagementPost-procedural Managementp gp g

• Close observation• Frequent symptom and sign (V/S) evaluation• Frequent symptom and sign (V/S) evaluation• Keep IV fluid• Recurrent chest pain or other symptom• EKG monitoringEKG monitoring• Neurological change

Post-procedural acute complicationsPost procedural acute complications

• Local complication at puncture site• Pericardial tamponade due to perforationPericardial tamponade due to perforation• Abrupt closure• Renal failure• Renal failure• Atheroembolism, CNS problem• H iti it ti d l d• Hypersensitivity reaction – delayed• Fatal arrhythmia• Bleeding

High Risk PatientsHigh Risk PatientsHigh Risk PatientsHigh Risk Patients

• Major complications in hospital mortality• Major complications in-hospital mortality• ST elevation MI

U t t b fti• Urgent coronary artery bypass grafting• Atheroembolism (Stroke)

• Minor complicationsp• Periprocedural cardiac enzyme elevation• Vascular access site problemsVascular access site problems

Procedural ComplicationsProcedural Complicationspp

• Stent thrombosis • Intramural hematomaIntramural hematoma • Side branch occlusion • Di t l b li ti• Distal embolization • Coronary artery perforation • Emergency CABG for failed PCI

Stent ThrombosisStent ThrombosisAbrupt persistent chest pain with ST

segment changesegment change

• Acute (<1 day)- due toIncomplete stent expansion,

uncovered dissection, intramural h thematoma

• S b t (1 30 d )• Subacute (1~30 days)

• Late (> 30 da s)• Late (> 30 days)- High in DES than BMS

Endothelization vs. Stent ThrombosisEndothelization vs. Stent Thrombosis

Stent ThrombosisStent ThrombosisPost-procedure 14 months after PCI

StrokeStroke

• 0.07 to 0.4 % after PCI• Due to air atheroma or thrombus• Due to air, atheroma, or thrombus• In most cases, it appears to occur in the setting

f t i th i th ti h th tof extensive atheroma in the aortic arch that are disrupted during guiding catheter advancement i t th iinto the coronaries

Acute Renal FailureAcute Renal Failure

• Hemodynamic instability• Radiocontrast toxicityRadiocontrast toxicity• Atheroembolism.

: most likely in patients with diabetes mellitus, chronic renal failure, shock or dehydrated patients

Atheroemboli Induced ARFAtheroemboli Induced ARF

AtheroemboliAtheroemboli

Th f tiffThe use of stiff, large-bore guiding

th t lt icatheters results in aortic trauma and the "scraping" ofthe scraping of atheromatous debris from thedebris from the aortic wall, providing aproviding a potential source of systemic embolism.y

Arrhythmia Arrhythmia yy

• PVC• Ventricular tachycardia or fibrillation• Bradycardia• Bradycardia

Ventricular tachycardia or fibrillation Ventricular tachycardia or fibrillation yy

• 0 4 percent of PCI0.4 percent of PCI

• D t• Due to- excess catheter manipulation - commonly from intracoronary contrast injection.

• The risk is greatest with injection of high osmolar contrast agents into RCA particularly in the settingcontrast agents into RCA, particularly in the setting of a prolonged injection or a damped pressure tracingtracing

Defibrillation forDefibrillation forDefibrillation for fatal arrhythmiaDefibrillation for fatal arrhythmiafatal arrhythmiafatal arrhythmia

200 J200 J

200 300 J200 - 300 J

360 J360 J

Allergic ReactionsAllergic ReactionsAllergic ReactionsAllergic Reactions

• Local anesthetic• Iodinated contrast agentsIodinated contrast agents

- occurs in up to 1%. hi h t i ti t ith hi t f i t t- highest in patients with a history of prior contrast reactions.

- Other conditions, such as asthma and other atopic diseases.

Pretreatment for patients withPretreatment for patients withPretreatment for patients with previous hypersensitivity

Pretreatment for patients with previous hypersensitivity

• Prednisone 50 mg orally 13,7, and 1 h g y , ,prior to procedure

• Diphenhydramine 50 mg PO/IM/ or IV 1 hDiphenhydramine 50 mg PO/IM/ or IV 1 h prior to procedure

• Lower / iso osmolar RCM should be• Lower / iso-osmolar RCM should be recommended

• Emergency therapy should be available• Emergency therapy should be available

Puncture site complicationPuncture site complicationPuncture site complicationPuncture site complication

• Hematoma – inguinal retroperitonealHematoma inguinal, retroperitoneal

• PseudoaneurysmPseudoaneurysm

• A-V fistulaA V fistula

Risk Factors for Vascular ComplicationRisk Factors for Vascular Complicationpp

• Periprocedural use of heparin or fibrinolytic therapy, especially if there is prolonged or excessive anticoagulation

• Repeat procedurep p• Peripheral vascular disease• ObesityObesity• Duration of time sheath remains in place,

particularly if >15 hoursparticularly if >15 hours• Use of intraaortic balloon pump

Radial Artery PunctureRadial Artery PunctureRadial Artery PunctureRadial Artery Puncture

Radial Artery PunctureRadial Artery PunctureRadial Artery PunctureRadial Artery Puncture

Femoral Artery PunctureFemoral Artery PunctureFemoral Artery PunctureFemoral Artery Puncture

Femoral Artery PunctureFemoral Artery PunctureFemoral Artery PunctureFemoral Artery Puncture

Vascular Closure Vascular Closure Manual CompressionManual Compression

Vascular Closure Vascular Closure Compressor CompressionCompressor Compression

Vascular Closure Vascular Closure Bandage CompressionBandage Compression

Device ClosureEff ti t d t it li ti

Device ClosureEff ti t d t it li tiEffective way to reduce puncture site complication

Angio-Seal DeviceEffective way to reduce puncture site complication

Angio-Seal Device

Take Home MessageTake Home MessageTake Home MessageTake Home Message

•Check ital sign (HR / BP)•Check vital sign (HR / BP) •Ch k h t i (EKG /•Check chest pain (EKG /

Chest X ray)Chest X-ray)•Check puncture site•Check puncture site •Check patient’s complaints !!!!•Check patient s complaints !!!!